A fairly long time ago in a land far away, a community paramedic program was conceived.
Community Paramedicine got its start in Canada back in 2001, on Long and Brier Islands, remote communities in southwestern Nova Scotia. This innovative project was developed based on a theory that patients could be treated at home instead of traveling over land and sea to be treated. The proposal also predicted that patients would be happier and that the government would save a significant amount of money.
It turned out to be a pretty good theory. Within a year, ambulance calls were reduced by 25 per cent and emergency room visits by 40 per cent. The average cost of health care for residents of the small communities fell from an average of $2,380 to $1,375, a reduction of 43 per cent.
In 2016, according to Statistics Canada, we spent about $4,087 per Canadian on health care. (37.95 million people in Canada X 4,087 dollars = $155,101.65). If we projected those same savings nationally, we would save $67 million per year on health care!
So how did they accomplish this miracle in health care? Well, instead of merely transporting the same patients over and over for the same issues, they started treating patients in their own homes. This hybrid team started doing wound care, suturing minor injuries, administering immunizations and antibiotics, checking patients’ adherence to prescriptions and anticipating and preventing flares ups from chronic disease.
Other similar pilot programs have provided equally impressive savings. In one Ontario community, they have realized a 50 per cent reduction in calls to 9-1-1 and a 65 per cent drop in ER visits.
These savings are generated by proactively caring for frail seniors with multiple chronic conditions. This is one of the fastest-growing demographics in health care. Unfortunately, the very people that built our country are now victims of our heath care system’s inefficiencies. Often these patients have no access to primary care, so they end up going to hospital by ambulance, being released and returned a short time later.
About a decade ago, the BC Ministry of Health recognized all of this and tasked the BC Emergency Health Services Commission with developing a similar plan. Rick Ruppenthal was one of the project leads and I sat down with him recently to get the history of the Community Paramedic Program in BC.
It’s an interesting story of ambition, innovation and determination.
The program in BC was initially proposed to provide meaningful work for under-utilized rural and remote paramedics. As the third most populated province in Canada, there has always been a challenge to provide emergency health services to the 162 municipalities covering 944,735 square kilometers of very difficult terrain. (There are 6,000 islands and over 75 per cent of the province is mountainous)
These geographical issues posed the biggest problem for the team—how to capture the success of Brier Island and transfer that to BC. But there were other hurdles as well. Initially, there was push back from some physicians. There where legitimate concerns about liability and scope of practice. Not to mention, push back from some allied health care unions for what was perceived to be encroachment into their profession.
Eventually working models where developed and the plan started to gain some traction. Isolated communities such as Tahsis, Ucluelet and Tofino where identified. These three communities hug the very western reaches of Canada on a beautiful but rugged coastline plagued by winter storms, treacherous roads and vulnerable patients. Ricks timeline was very short as the Ministry of Health was very concerned about developments
that were eroding health care in remote areas. During those years, many small towns in BC where actually shrinking in size. RCMP were leaving the communities, nurses where leaving, and many doctors where retiring and new doctors were not interested in relocating to such small and underserviced towns. Something had to be done, and fast.
It didn’t take long before Rick and his team had a pretty good handle on the opportunities, the challenges and the solutions. One obvious opportunity surfaced in Tofino. Although Tofino wasn’t suffering the fate of many other small towns, there were still gaps in staffing. Patients could only be discharged from the hospital when the homecare nurse was in town, and this was only two days a week. As you might imagine, it wouldn’t take long for paramedics to successfully master the required skills to serve this important function. And so, the concerns regarding scope of practice where minimized by simply reducing the scope of practice. Although this initially seemed like a big loss for the development team, as it turns out, much can be accomplished through great history taking, simple assessments and a preventative approach. But I’m getting ahead of myself.
The project actually was suspended before if flourished. There where many reasons for pulling the plug. First of all, there was limited funding for this project. The development, training and deployment had to be covered before any of the cost benefits could be realized. The concerns regarding expanding the paramedic scope of practice compromised most of the real benefits that the program offered. Doctors had real concerns about paramedics assessing complex patients and missing something important. Nurses asked legitimate questions such as, why fund a paramedic to do discharges in Tofino when you should really be providing more funding for nurses. Because the scope of the project was so difficult to define, there were many assumptions by paramedics that were not necessarily true. There were items that were not part of traditional paramedic training or experiences and some paramedics felt that this was not what they signed up for.
There’s an old saying that a camel is just a horse designed by a committee and it’s fair to say that some paramedics really didn’t like the look of this particular animal.
Eventually, time ran out and the project was shelved.
But then something unexpected happened. About 2 or 3 years later, the BC Emergency Health Services Commission was taken over by the Provincial Health Services Authority. This is a publicly funded health service provider that is unique in Canada as the only health authority having a province-wide mandate for specialized health services. PHSA brought it’s 2.78-billion-dollar budget to the table and all of a sudden things began to change. The program was resurrected, scope of practice for paramedics was expanded and nine trial communities where identified. Today over 99 communities are serviced by community paramedics and the goal is to create 80 full time equivalent positions.
Interestingly enough, many of the original challenges faced by Rick and his team turned out to be the factors that ultimately led to success. Although it was difficult to define roles and responsibilities due to the diverse nature of British Columbia, this lack of a cookie cutter approach allowed the flexibility required to make this work for each community.
Recently, I spoke with a few community paramedics to learn how the program was working. Those that I spoke to loved their job. They function quite independently and work to develop a unique preventative health care program for their community. Initially, they identify gaps that can be filled. Then they engage with the community in a collaborative way to set up programs. The role is very different from emergency medicine as it prevents disease and promotes health. There is a lot of teaching and relationship building. They don’t describe those in their care as patients but as clients and the elderly people in their communities absolutely love them.
One of the great strengths of the program is that there is time for the community paramedics to sit down with their clients and talk. As we all know, this is such a rare thing in our existing health care system. Doctors and nurses are so busy and over tasked that they seldom have the time to just sit and listen. But as you might imagine, listening is critical component of history taking. These sessions build trust and often the patients or their families divulge information that dramatically impacts health and prevents disease. One such example is a case involving an elderly client who was becoming more confused and unable to care for himself. An afternoon visit with the client and his family revealed that although he was very compliant with his morning medications, he was rarely taking his evening medications. The paramedic consulted with the family doctor and changes where made to the client’s medication schedule. The result was dramatic and has greatly increased his quality of life and that of his family. I heard many stories of simple common-sense solutions having a major impact on the client’s health. By conducting wellness clinics and educating seniors, community paramedics have an impact on many as opposed to the traditional paramedic role where our impact is limited to the one patient that we are caring for.
But the job can be also be tough at times and community paramedics must find a balance between developing close relationships and maintaining an appropriate professional distance. This can be very difficult to navigate especially when a long-term client passes away.
Sometimes, the doctors don’t even read the progress notes and the patient falls through the cracks and winds up in the hospital unnecessarily. Occasionally, skills get degraded due to a lack of exposure to acute calls. Every so often, there is a realization that more technical skills are required.
But the thing that really stood out for me is how satisfied community paramedics are with their role in health care. It’s a completely different opportunity for paramedics. Rather than sorting out the issues in a crisis, they get to solve those issues before they happen. What a great way to help people.